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Tutorial-stroke
Neurology tutorial Approach to stroke- a case NUS YLLSOM Year 3 CG 21 1. History a. Acute onset of confusion and slurring of speech b. Associated with non-fluent speech, unable to say the names of staff c. Still able to ambulate d. No headache, giddiness, blurring of vision, neck stiffness ACUTE ONSET NEUROLOGICAL DEFICIT COMPATIBLE WITH A VASCULAR ETIOLOGY-LIKELY STROKE 2. On examination a. CVS: i. Right carotid bruit ii. No murmurs, pulse regular b. Cranial nerves: i. right homonymous hemianopia ii. right facial droop (UMN VII pattern), iii. extra-ocular range of motion full c. Limbs: i. Mild pronator drift present ii. No limb weakness or sensory loss; reflexes 2+ universally, bilateral plantars downgoing d. Cerebellar signs: no dysmetria e. Neglect: right-sided neglect f. Constructional dyspraxia: unable to draw necker’s box 3. Localize stroke (e.g. left hemiplegia with slurred speech: look for localizing signs) a. No brainstem signs of nystagmus, dysmetria, no cranial nerve palsies b. Cortical signs present i. Visual field testing - right homonymous hemianopia ii. Expressive dysphasia and nominal dysphasia – Broca’s dysphasia iii. Right-sided neglect – line bisection to the left 1. No sensory neglect - equal on both sides iv. Constructional dyspraxia 1. Unable to draw http://images2.wikia.nocookie.net/__cb20100413152448/one/images/2/20/400px-Necker_cube.svg.p (although more of a right-hemispheric sign) c. Therefore, likely left-sided hemispheric syndrome 4. Likely ischemic stroke, not hemorrhagic a. No previous TIA b. Onset over several hours c. Confirmed by MRI brain 5. If ischemic a. Not small vessel disease i. Does not fit into any lacunar syndrome IE NOT PURE MOTOR, PURE SESNORY OR ATAXIC HEMI PARESIS BUT; b. Likely large vessel disease causing hemispheric lesions (i.e. left MCA territory infarction) i. Embolism 1. No gross cardiac abnormality e.g. AF a. CVS exam: apex beat not deviated, heart sounds normal, no murmurs, no irregular rhythm b. ECG: no abnormal rhythm, no ST changes or Q waves c. CXR: normal d. 2DE: aortic sclerosis detected, EF 60% e. Therefore, no anti-coagulation required 2. Extra-cardiac source of thrombosis/embolism likely a. CVS exam: right carotid bruit b. U/S carotids: not done c. CT angiogram: severe steno-occlusion of both ICAs d. Therefore, consider endarterectomy if: i. Stenosis on symptomatic left side is extracranial ii. >70% iii. fit for GA/surgery ii. Important to manage risk factors for cardiovascular disease in ischemic stroke 1. Control of chronic disease: hypertension and hyperlipidaemia 2. Smoking cessation-THE IMPORTANT ROLE OF THE DR.. 3. DM screening 6. Acute issues a. Expressive dysphasia i. Watch for accompanying dysphagia – may require diet modification or NGT feeding b. Right-sided homonymous hemianopia and hemineglect c. Constructional dyspraxia d. Anticipate and manage complications of i. Aspiration pneumonia ii. Associated with immobility – DVT, UTI, constipation iii. Depression 7. Secondary prevention strategies a. Anti-platelets: aspirin b. Control vascular risk factors i. Hypertension: monitor and consider pharmacological therapy if required ii. Hyperlipidaemia: statins to control iii. Counsel on smoking cessation 8. Rehabilitation a. Deficit i. Expressive dysphasia ii. Right-sided homonymous hemianopia and hemineglect iii. Constructional dyspraxia b. Disability i. Unable to communicate in a social setting 1. Requires speech therapy ii. Difficulty in self-care and personal grooming 1. Requires occupational therapy iii. Poor safety awareness due to hemianopia and hemineglect 1. Requires occupational and physiotherapy and home visit to ensure safety c. Handicap i. May result in social isolation 1. Consider step-down care or rehabilitation to reduce disability and improve function (as mentioned above) 2. Consider BEFRIENDER programme 3. consider safe SSRIs like fluoxetine 4. MSW to involve family before discharge ii. May require assistance in his activities of daily living 1. OT to r/v 2. Assess if caregiver/care-coordinator required (lives alone) 3. May sustain injuries and suffer from frequent falls a. May need advise on safety/home modification – occupational therapy b. Osteoporosis screening (DEXA scan) and prophylaxis